My SLP Isn't Listening: 5 tips for better communication
Meet Paul, a 76-year-old male with a history of Parkinson's disease. Paul was admitted to the hospital with a headache and altered mental status. After a few hours, he appeared to be approaching his baseline, but the attending physician kept him overnight for observation. Paul was from a nursing home nearby, but this was his first visit to the hospital. He had been relatively stable before this with just some support for his daily activities. Paul was generally awake, alert, and oriented x3, albeit with mild confusion. Meanwhile, SLP Stefania, who has seen 11 patients today and hopes to go home for the night, answered her work phone while walking out the door. "Another order? Right now? Can't it wait until tomorrow? He's NPO? OK, I'll be right over."
This scenario might look familiar to you. If it's not, you're one of the lucky ones. An enormous percentage of healthcare workers are experiencing exhaustion and burnout. The job can seem impossible with too many patients, insufficient staff, and insufficient time. Correction: the job is impossible. A special kind of person sticks it out in this environment—an empathetic, hard-working idealist who wants to help patients get better. If you're like most SLPs, this describes you perfectly. Unfortunately, no matter how idealistic you are, working in this environment can lead to short-changing our patients on the time needed to communicate with them effectively. And that's precisely what happened with Paul.
"Hi, I'm your SLP, and I'd love to help you. Can you tell me a little about what's going on? Paul then leaps into a long description of his current and past issues, many of which have nothing to do with speech, language, or pathology. "Hold on, wait a second. Can we back up? First, can you tell me how you're eating and drinking?" Next, Paul tumbles into a saga of his dysphagia ranging from globus sensation to weight loss to missing teeth, some of which are current symptoms and others resolved long ago. Stefania does her best to make sense of all this, but she's growing frustrated with the complexities and how long the conversation is taking. She's tired. She's hungry. She wants to go home and see her family.
The Breakdown
Communication breakdown is widespread in healthcare and can have tragic outcomes. Communication can be especially challenging when there are many variables to consider, different people with different communication styles, and in a high-stake/high-stress environment. This, of course, doesn't change the fact that it's vitally important and, if done right, can significantly improve patient satisfaction, adherence to recommendations, and health outcomes. Even drug companies can't promise those kinds of results.
"OK, now that I have completed your clinical swallow assessment, let's start from the beginning. What were you eating and drinking in the nursing home?" Stefania asks.
"Well, I was eating regular food, but certain foods, like cookies and crackers, were hard to get down."
"Why don't we put you on an IDDSI minced & moist, level 5 diet, then? That will make it easier to chew and swallow, especially with your incomplete dentition.
"Minced & moist? Does that mean it's mushy? Because I think..." Paul starts to say.
"Kind of, well, not really. It's just cut up into small pieces to make it easier. That's the best thing for you right now," Stefania answers.
"I don't know. They put me on something like that in the nursing home one time, and I really didn't..." Paul tries to respond but is cut off by Stefania.
"I truly think this is the best option for you right now. I'm so sorry, but I have to go. Let us know if you need anything else, OK?"
How much time can we spare?
One study found that doctors only give patients 11 seconds before they cut them off with a close-ended question. 11 seconds. How much can you get out in 11 seconds? Even my five-year-old gives me more time than that before he interjects with his plans to turn the basement into an assortment of booby traps. Medical practitioners, including SLPs, constantly try to find the critical issue... The chief complaint... The most important thing. In many ways, this is useful. It allows for a more efficient plan of care that addresses the core concern. However, communication rarely works that way.
We aren't machines. And if a patient is anxious, concerned, and confused, this process can be even less direct. We must give our patients the floor when they discuss their concerns. By doing so, we allow everything to get aired out. By listening intently, asking open-ended questions, and giving space, we can discover hidden concerns or problems that otherwise would never have made it to the surface. We can better understand what's most important to the patient, their goals, and what direction they would like the plan of care to go in. The bonus: It may take less time than you think. In Danielle Ofri's "What Patients Say, What Doctors Hear," she finds that it only takes 30 seconds to a minute for most patients to get their whole story out. Can we spare that? A minute? That 60 seconds could save you multitudes more if you have to reverse your plan of care and adjust when you later find out that you were completely off base.
A couple of months later, Stefania sees another consult order in her inbox to provide a swallow evaluation for Paul. This time, it's because of weakness secondary to malnutrition and weight loss. It turns out he was never upgraded back to his regular baseline diet. Paul's been trying to get down as much of the IDDSI minced & moist, level 5 diet as possible, but he says, "It's just not edible. Everything looks blended up. Would you eat blended-up meat and vegetables?" Stefania felt horrible. She just wanted to do what was safest for Paul. Still, because the conversation was rushed and the communication poor, she didn't realize that he never planned on truly following her recommendations in the first place.
5 Quick Tips
Communication isn't rocket science. Most of us, especially as SLPs, intuitively know how to communicate effectively. But it's easy to forget in the stale, rushed environment of the hospital. Thankfully, Danielle Ofri offers some easy tips that can dramatically improve our communication:
Take a minute to introduce yourself, explain what you'll do, and speak informally with the patient before getting into the exam. This humanizes the patient's experience, which can lead to building rapport. This can lead to trust, and trust can lead to comfort and honesty, which is what you need if you want effective communication.
Give the patient time and space to tell their story. It shouldn't take long. Don't interrupt (No matter how badly you want to interject with a question). After the patient finishes, you can ask, "Is there anything else?" or "Tell me more," or "Go on" as many times as you need to until everything is out in the open.
Have and show empathy. Commenting on how challenging the situation must be and asking if the patient is OK or needs anything can go a long way. You'd be surprised at how infrequently this is done for patients.
Clarify your understanding of what the patient said to ensure you got everything. "Let me see if I got this right. So you're saying..." If a patient's explanation is long and complicated, consider asking, "What is the most challenging part of your condition?" This can cut straight to the core issue if the water seems muddy.
After your physical examination, explain what you think is going on and what you'd like to do, and ask them what they think about that plan and if they have any questions.
Communication Heals
Still have doubts about the power of communication? Then consider this: Communication, connection, and empathy can have a healing effect that rivals or beats the effectiveness of certain medications. For example, Danielle Ofri tells us that reassuring the patient may physically decrease pain by reducing cortisol and adrenaline and increasing endorphins. Whoa. Just talking to the patient can act as a pain pill? The best part? Communication is cheap and doesn't include any nasty side effects that you may expect with certain medications (or modified diets for that matter).
Stefania has learned her lesson from the first botched attempt to communicate with Paul. This time, she uses the strategies mentioned above. By giving Paul time and space to speak, she finds out that he has been on a modified diet in the past and didn't eat it then either (surprise, surprise). He knows it's easier to swallow but can't bring himself to eat it. "It makes me sick," he says. After re-examining Paul, Stefania quickly advances his diet back to regular to try to get him back on track. She orders a modified barium swallow study followed up with an esophagram to address his complaints of globus sensation. Stefania also refers him to a dentist to be fit for dentures. She explains the risks of choking with inadequate dentition, which Paul acknowledges. He's also receptive to her recommendations to avoid hard, crunchy food, to maintain an upright posture, slow pacing, and to alternate solids and liquids to reduce his risk. Because Stefania listened so intently to Paul, he found it easy to listen to her recommendations and, ultimately, to follow them. They discuss pros/cons, risks/benefits, and alternatives to the plan of care. Even though so much was covered, the entire visit only took 11 minutes.
Communication might be the most critical tool in healthcare. It's the oil to the gears; nothing will function properly without it. It's also why many of us got into the field in the first place. We want to listen, learn, connect, and build relationships with our patients. It's what quality care is all about. Yes, time gets in the way. An impossibly high caseload becomes overwhelming. Medical complexity with multiple moving parts is so hard to manage. But there's still a difference to be made. One patient at a time. No matter how small. It starts with connecting with the patient, making sure they are fully heard, and improving their chances of getting better. That’s what I call time well spent.
***Don’t miss this. Offer ends soon: Let Us Eat: The ethics of swallowing in older adults at high risk
